Inspection Reports for Cedar Grove Respiratory And Nursing Center
1420 South Black Horse Pike, NJ, 08094
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 164
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ00182979.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint #: NJ00182979; the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 0
Jan 30, 2025
Visit Reason
The inspection was conducted in response to complaints NJ00175665 and NJ00176551 to assess compliance with long term care facility regulations.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and in compliance with New Jersey Administrative Code Chapter 8:39 standards for licensure of long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ00175665 and NJ00176551 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 0
Aug 19, 2024
Visit Reason
The inspection was conducted in response to complaints NJ176223 and NJ176232 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, and the New Jersey Administrative Code, Chapter 8:39, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ176223 and NJ176232 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
May 9, 2024
Visit Reason
The inspection was conducted based on complaints NJ171632 and NJ173434 to investigate compliance with staffing ratios and other regulatory requirements.
Findings
The facility was found to be in substantial compliance overall but was deficient in meeting mandatory staffing ratios on 2 of 14 day shifts reviewed, potentially affecting all residents. No negative outcomes were reported. The facility implemented corrective actions including recruitment efforts, staff training, and monitoring.
Complaint Details
Complaint numbers NJ171632 and NJ173434 triggered the investigation. The facility was found deficient in staffing ratios but no negative outcomes were identified. The complaint was substantiated with findings of staffing deficiencies.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 2 of 14 day shifts reviewed, specifically CNA staffing was deficient on 04/14/24 and 04/15/24. |
Report Facts
Census: 123
Deficient shifts: 2
CNA staffing on 04/14/24: 21
CNA staffing on 04/15/24: 21
Residents on 04/14/24: 177
Residents on 04/15/24: 173
Certified Nursing Assistants hired: 8
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 1
Dec 8, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers from 12/05/2023 to 12/08/2023.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities due to failure to protect a resident from abuse by another resident. The investigation revealed deficiencies related to abuse, neglect, and failure to prevent resident-to-resident altercations.
Complaint Details
The complaint investigation involved multiple complaint numbers and focused on allegations of abuse and neglect between residents R19 and R23. The investigation included interviews, record reviews, and policy reviews. The facility failed to prevent resident-to-resident abuse and did not substantiate the allegations fully but was found deficient in protecting residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect the resident's right to be free from abuse by another resident, including verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. | SS=D |
Report Facts
Sample Size: 31
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Aug 17, 2023
Visit Reason
The inspection was conducted based on complaint NJ166463 to investigate staffing ratio compliance at the facility.
Findings
The facility was found to be deficient in meeting required staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed, potentially affecting all residents. The facility has implemented multiple corrective actions including recruitment efforts, staff education, and increased use of agency staff.
Complaint Details
Complaint NJ166463 was substantiated with findings that the facility failed to meet minimum staffing requirements for CNAs on all 14 day shifts reviewed, potentially affecting all residents.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts reviewed, violating mandatory access to care requirements. |
Report Facts
Census: 169
Deficient shifts: 14
Required CNAs per day shift: 21
Actual CNAs on day shifts: Varied from 15 to 19 CNAs on day shifts, all below required 21 CNAs.
Certified Nursing Assistants hired: 10
Inspection Report
Routine
Census: 172
Deficiencies: 15
May 18, 2023
Visit Reason
Standard survey of Cedar Grove Respiratory and Nursing Center to assess compliance with federal and state regulations, including complaint investigations.
Findings
The facility was found not in substantial compliance with several regulatory requirements including safe environment, respiratory care, pain management, pharmacy services, food safety, resident call system, staffing ratios, fire safety, and life safety code requirements. Deficiencies were cited in areas such as meal service, oxygen equipment storage, medication administration timing, controlled substance recordkeeping, expired food handling, call system accessibility, staffing shortages, fire evacuation signage, smoke barrier doors, kitchen ventilation, and exit illumination.
Complaint Details
Complaints NJ00160866 and NJ00164241 were investigated, including issues with pain management, staffing ratios, and medication administration.
Severity Breakdown
SS=D: 10
SS=E: 3
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to create a homelike dining environment by serving meals on plastic trays instead of placemats. | SS=D |
| Failed to contain oxygen/nebulizer delivery systems properly to prevent infection spread. | SS=D |
| Pain medication administered outside of prescribed time windows. | SS=D |
| Failed to maintain accurate and complete DEA 222 forms and controlled medication count logs. | SS=D |
| Failed to store Tubersol injection in accordance with manufacturer's refrigeration requirements. | SS=D |
| Failed to provide all menu items as listed; substituted dessert without prior dietitian approval. | SS=D |
| Failed to discard expired food items and maintain proper sanitation including hairnet use by dietary staff. | SS=E |
| Resident call system handset was found on the floor and not within reach of the resident. | SS=D |
| Failed to maintain required minimum direct care staff to resident ratios on multiple shifts. | — |
| Failed to post emergency evacuation diagrams with fire alarm pull stations and fire extinguisher locations on all resident units. | — |
| Failed to provide continuous illumination with two lamps at designated exit discharge doors. | SS=E |
| Failed to provide illuminated exit signage to clearly identify exit access paths at six locations. | SS=F |
| Range hood grease baffles were damaged allowing potential fire and grease vapor entry into exhaust system. | SS=D |
| Smoke barrier doors failed to close properly leaving a gap that could allow smoke and fire to pass between compartments. | SS=D |
| Failed to maintain proper ventilation in 3 of 10 resident bathroom exhaust systems. | SS=E |
Report Facts
Census: 172
Sample Size: 38
Staffing Deficiencies: 13
Staffing Deficiencies: 14
Staffing Deficiencies: 3
Medication Administration Timing: 14
DEA 222 Forms: 7
Resident Bathrooms with Exhaust Issues: 3
Designated Exit Doors: 19
Exit Signs Missing: 6
Smoke Barrier Doors Tested: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in controlled medication count log deficiency |
| RN/UM #1 | Registered Nurse/Unit Manager | Interviewed regarding respiratory equipment storage and narcotic count procedures |
| DON | Director of Nursing | Interviewed regarding medication administration timing, respiratory equipment storage, and call system placement |
| ADON | Assistant Director of Nursing | Interviewed regarding DEA 222 form completion and respiratory equipment storage |
| DD | Dietary Director | Interviewed regarding menu substitutions and food safety |
| SC | Staffing Coordinator | Interviewed regarding staffing shortages |
| DOM | Director of Maintenance | Interviewed and observed regarding fire safety, exit signage, smoke barrier doors, ventilation, and kitchen equipment |
Inspection Report
Life Safety
Deficiencies: 5
May 9, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/09/2023 and 05/10/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with several Life Safety Code requirements including inadequate illumination of means of egress, insufficient exit signage, damaged cooking facility grease baffles, improperly maintained smoke barrier doors, and malfunctioning bathroom exhaust ventilation systems. Corrective actions were planned and implemented for each deficiency.
Severity Breakdown
SS=E: 2
SS=F: 1
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure continuous illumination for 2 of 19 designated exit discharges, with single light bulb fixtures insufficient to maintain required illumination levels. | SS=E |
| Failed to provide six illuminated exit signs to clearly identify the exit access path to reach an exit discharge door. | SS=F |
| Failed to maintain range hood grease baffles; two grease baffle filters were missing metal pieces, leaving openings that could allow fire and grease vapors to enter the exhaust system. | SS=D |
| Failed to maintain smoke barrier doors to resist transfer of smoke when closed; a 1/2 inch wide by 8 inch high gap was observed at the bottom of one set of corridor smoke barrier doors. | SS=D |
| Failed to ensure proper maintenance of ventilation systems; 3 of 10 resident bathroom exhaust systems did not function properly during testing. | SS=E |
Report Facts
Designated exit discharges: 19
Illuminated exit signs missing: 6
Resident bathroom exhaust systems inspected: 10
Resident bathroom exhaust systems malfunctioning: 3
Sets of corridor smoke barrier doors tested: 17
Sets of corridor smoke barrier doors deficient: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in relation to findings and corrective actions for illumination, exit signage, smoke barrier doors, and ventilation systems | |
| Administrator | Informed of deficiencies at Life Safety Code exit conference and involved in monitoring compliance | |
| Food Service Director | Involved in corrective actions and monitoring for cooking facility grease baffles |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 1
Jan 17, 2023
Visit Reason
The inspection was conducted based on complaints NJ159660, NJ160372, and NJ160433 to investigate compliance with staffing requirements and other regulatory standards.
Findings
The facility was found to be in substantial compliance with federal long-term care requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to meet minimum certified nurse aide (CNA) staffing ratios for 14 of 14 day shifts and 11 of 14 evening shifts.
Complaint Details
The complaint investigation was based on complaints NJ159660, NJ160372, and NJ160433. The facility was found deficient in CNA staffing ratios on multiple days during the review period, but no residents were negatively affected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios met the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 14 of 14 day shifts and 11 of 14 evening shifts. |
Report Facts
Census: 180
Staffing Deficiency Days - Day Shift: 14
Staffing Deficiency Days - Evening Shift: 11
Sample Size: 4
Staffing Ratios Examples: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource Director | Named in the plan of correction for staffing shortages and responsible for implementing corrective actions. |
Document
Deficiencies: 0
Jul 1, 2022
Visit Reason
The document is a PDF portfolio that cannot be viewed without specific software; no visit or inspection reason is stated.
Findings
No findings or inspection content available due to inaccessible document format.
Document
Deficiencies: 0
Feb 23, 2022
Visit Reason
This document does not contain an inspection or regulatory visit reason.
Findings
No inspection findings or content are present in this document.
Inspection Report
Life Safety
Census: 166
Capacity: 180
Deficiencies: 9
Feb 14, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be noncompliant with several life safety code requirements including failure to conduct daily inspections of construction egress, inadequate discharge from exits, lack of continuous lighting in courtyards, missing emergency lighting at transfer switches, lack of fire alarm notification in courtyards, missing tamper alarms on sprinkler valves, painted sprinkler heads, damaged smoke barrier doors, and unmaintained HVAC PTAC units.
Severity Breakdown
SS=E: 3
SS=F: 5
SS=D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to conduct daily inspection of construction repair, alterations or additions and means of egress. | SS=E |
| Failed to provide and maintain a level walking surface free of obstructions at exit discharge. | SS=F |
| Failed to provide continuous lighting in 2 enclosed courtyards. | SS=E |
| Failed to provide operational battery backup emergency lighting above emergency generator transfer switches. | SS=F |
| Failed to provide fire alarm notification by audible and visible signals in 2 enclosed courtyards. | SS=F |
| Failed to maintain fire sprinkler system water supply valves with tamper alarms. | SS=F |
| Failed to maintain automatic sprinkler system; 4 sprinkler heads had paint on frangible bulbs and spray heads. | SS=E |
| Smoke barrier doors failed to completely close and resist passage of smoke, flame or gases due to damaged astragals and door rubbing on floor. | SS=D |
| Failed to maintain PTAC units in safe and optimal condition; 4 of 85 units had clogged and dirty filters. | SS=F |
Report Facts
Certified beds: 180
Census: 166
PTAC units observed: 85
PTAC units deficient: 4
Sprinkler heads painted: 4
Smoke doors tested: 8
Smoke doors deficient: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 1
Oct 7, 2021
Visit Reason
The inspection was conducted based on a complaint survey to determine compliance with staffing requirements at the facility.
Findings
The facility failed to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey for multiple days during two separate weeks in 2021. The facility was deficient in CNA staffing for 7 of 7 day shifts during the week of 4/4/21 to 4/10/21 and 6 of 7 day shifts during the week of 9/5/21 to 9/11/21.
Complaint Details
Complaint #NJ 148441. The complaint was substantiated as the facility did not meet minimum staffing levels for multiple day shifts. No residents were negatively affected.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff to resident ratios for the day shift as mandated by the State of New Jersey. |
Report Facts
Census: 171
Deficient CNA staffing days: 7
Deficient CNA staffing days: 6
Required CNAs: 21
Actual CNAs: 14
Required CNAs: 23
Actual CNAs: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed by surveyor regarding staffing; discussed staffing crisis and facility efforts to increase CNA hourly rates and recruitment |
Inspection Report
Routine
Census: 162
Deficiencies: 0
May 5, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 151
Deficiencies: 1
Feb 11, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint # NJ 142902) to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to timely update and implement a care plan for contact isolation for one sampled resident (Resident #6). The facility also failed to follow its policy titled 'Care Plans, Comprehensive Person-Centered.'
Complaint Details
Complaint # NJ 142902. The facility was not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to update and implement a care plan timely for contact isolation for Resident #6. | SS=D |
Report Facts
Sample size: 6
Inspection Report
Abbreviated Survey
Census: 143
Deficiencies: 0
Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 0
Nov 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ 138598.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint number NJ 138598 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 8
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